Foundations and Essentials for the Doctor of Nursing Practice
Challenges in the Critical Care Workplace
©2020 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2020915
Background Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical con- flicts escalate, patient and family distress and dissatis- faction with care increase and trust in clinicians erodes, reducing care quality and patient safety. Objective To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. Methods In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via mul- tivariate logistic regression controlled for patient variables. Results The odds of receiving a family conference and a chaplain visit were significantly higher after the inter- vention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. Conclusions When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced. (American Journal of Critical Care. 2020;29:49-58)
A TEAM-BASED EARLY ACTION PROTOCOL TO ADDRESS ETHICAL CONCERNS IN THE INTENSIVE CARE UNIT By Carol L. Pavlish, PhD, RN, Joan Henriksen, PhD, RN, Katherine Brown- Saltzman, MA, RN, Ellen M. Robinson, PhD, RN, HEC-C, Umme Shefa Warda, MS, Christopher Farra, MS, RN, Belinda Chen, MPH, and Patricia Jakel, MN, RN, AOCN
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E thical conflicts during the provision of care for critical and chronic illness occur for multiple reasons: advancing technologies, extended lives, the public’s high expecta- tions of medical care, increasing cultural and religious diversity, the patients’ rights movement, and health care financing shifts, along with limited resources.1-7 In the Conflicus study, 71.6% of 7498 intensive care unit (ICU) nurses and physicians in
24 countries reported a perceived ethical conflict in the week before the survey day.1 In 255 ethics consultation cases, researchers found that most involved multiple ethical conflicts including staff disagreement with plan of care (76%), end-of-life issues (60%), and treatment decision-making concerns (54%). Forty percent involved critical care patient situations.8
Ethical conflicts can emerge from intractable
treatment disagreements9 or “when patients, surro-
gates, or clinicians perceive their goals related to
care and outcomes are being thwarted by the incom-
patible goals of others.”10(p342) The primary ethical
conflicts perceived in the ICU relate to medical
decision-making and treatment goals, especially
regarding the benefit or harm of aggressive treat-
ment.1,2,9,11 Shared decision-making requires accu-
rate information exchange and astute communication.
However, communication problems between surro-
gates and clinicians are frequently evident.
In California, 48% of ICU clinicians reported
communication difficulties between families and
ICU teams, and 68% believed
that they could not influence
a situation when asked to
provide potentially inappro-
priate treatments.5 Discordant
expectations about prognosis
between surrogates and phy-
sicians were apparent in
53% of 229 ICU situations.12
Delaying or avoiding conver-
sations about prognosis and treatment options
appears to increase the probability of continuing
aggressive and sometimes unwanted treatments for
patients with serious and life-limiting conditions.13,14
For example, patients with heart failure are often not
referred for palliative care services until the last month
of life because advance care planning is frequently
delayed.15 Other researchers found that Medicare
recipients with cancer received high-intensity treat-
ments relative to their poor prognosis in the last
weeks of life.16 Providing intensive therapies may
certainly be indicated in some cases; however, when
patients know that medical interventions are not
likely to improve their condition, they often refuse
or decrease intense measures.17
Ethical conflicts contribute to distress and anxi-
ety among patients and their family members.18-21
A systematic review of 40 studies involving 2854
surrogates revealed that making difficult decisions
had a negative emotional impact on at least one-third
of respondents, and the impact was often reported
as substantial and lasting months to years.22 Poor
decisional support, inadequate or conflicting infor-
mation, the emotional burden of caring for a criti-
cally ill family member, and inadequate sleep can
result in a family ICU syndrome that impairs family
members’ comprehension of complex medical
information and rational decision-making.20
Research on team-based interventions to prevent
ethical conflicts in the ICU is limited. In a multicenter
randomized trial, ethics consultations were effective
in decreasing conflicts.23 A systematic review and meta-
analysis of ethics consultations in adult ICUs showed
that ethics consultations increased the probability
of reaching decision consensus and shortening ICU
stay.24 The Veterans Health Administration has called
for a more systematic and proactive approach to
managing ethical conflicts.25 Other researchers have
urged quality improvement and system redesign to
prevent ethical conflicts.6
We evaluated the effectiveness of a proactive,
team-based ethics protocol to promote ethics-related
discussion and activate early family conferences and
About the Authors Carol L. Pavlish is an associate professor, Umme Shefa Warda is a senior statistician, Christopher Farra is a research assistant, and Belinda Chen is a statistician, University of California, Los Angeles, School of Nursing, Los Angeles, California. Joan Henriksen was the coordi- nator, Clinical Ethics Consultation Service, Mayo Clinic, Rochester, Minnesota; she is now senior staff ethicist at Children’s Minnesota in Minneapolis. Katherine Brown- Saltzman is a codirector, Ethics Center, and Patricia Jakel is a clinical nurse specialist, Santa Monica Hospital, Uni- versity of California, Los Angeles, Health System, Los Angeles, California. Ellen M. Robinson is a nurse ethicist, Massachusetts General Hospital, Boston, Massachusetts.
Corresponding author: Carol L. Pavlish, PhD, RN, FAAN, 5-954 Factor Building, 700 Tiverton Ave, Los Angeles, CA 90095 (email: cpavlish@sonnet.ucla.edu).
Most ethical conflicts in intensive care units
pertain to medical decision-making and
treatment goals.
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referrals for additional support services in 6 ICUs at
3 academic medical centers. We hypothesized that
this intervention would increase the number of and
shorten the time to family conferences and code dis-
cussions and provide additional support for patients
and families as they adjusted to critical illness, pos-
sibly shortening the ICU stay.
Methods This quasi-experimental, pre-post (3 and 6
months) study was undertaken to investigate the
effect of an ethics intervention on primary and sec-
ondary clinical outcomes and clinician outcomes.
Clinical outcomes are reported in this article. At least
1 nurse researcher was responsible for study proce-
dures at each hospital. The institutional review board
at each medical center approved the study.
Setting and Population Six ICUs representing 5 specialties in 3 academic
medical centers participated in this study: a surgical/
trauma unit, a cardiac surgery unit, a transplant unit,
a neurologic unit, and 2 medical units. All 5 types
of ICU were included in the preintervention and
6-month postintervention data collection periods.
Data were collected from 3 specialty units (medical,
transplant, and neurologic ICUs) in the 3-month
postintervention period. All ICU admissions during
1 month before the intervention (N = 672) and during
1 month in the 3-month (N = 438) and 6-month
(N = 602) postintervention periods were included in
the study. The total number of admissions was 1712,
representing 1649 patients; 63 patients were read-
mitted during the data collection period. Intensive
care unit admissions rather than patients were used
as the standard of measure because the ethics inter-
vention was initiated for all patient admissions and
not just for first-time admissions.
Intervention The ethics intervention comprised 3 parts: (1)
completion of a daily Ethics Early Action Protocol
(see Figure 1, available online only at www.ajccon-
line.org) requiring clinicians to analyze patient, fam-
ily, and situational risk factors that, on the basis of
evidence from physicians, nurses, and clinical ethi-
cists,26,27 indicate low, medium, or high risk for ethi-
cal conflict, with each risk level accompanied by an
action plan; (2) an interactive, case-based protocol
orientation developed by the authors of this article
and delivered to ICU staff as a 15-minute, online
video module; and (3) an ethics application devel-
oped by 2 of the authors (C.L.P., K.B.-S.) as an
ongoing resource and support for health care teams
as they implemented the ethics protocol, which
defined ethics terms, provided communication
guidelines for educating and supporting patients
and families or surrogates, and offered resources
for clinician and team well-being.
The Ethics Early Action Protocol integrated into
daily care was the central feature of the ethics inter-
vention. It was first pilot tested as a screening tool
in ICU and oncology settings at 2 major medical
centers.28 The protocol was refined on the basis of
the results. Subsequently, to establish content valid-
ity, 14 nationally known ethics experts (researchers,
physicians, registered nurses, and social workers)
assessed each protocol item
for its relevance to ethical
conflicts and appropriate-
ness for follow-up action.
Two items in the protocol
were deleted, 1 item was
added, and 5 items were
subsequently revised for
clarity. Nurses in the pilot
study also suggested ongo-
ing educational support,
specifically on ethics-related
communication. The ethics
application was developed
as a ready resource for these
conversations. For the current study, health care teams
were urged to incorporate the protocol into an exist-
ing care process in the ICU such as daily rounds. Most
units assigned nurses to routinely initiate the ethics
assessment and then alert the multidisciplinary team
as needed to discuss an appropriate plan to mitigate
the noted risk factors.
Clinical Outcome Measures Research team members all used the same defini-
tions for the primary outcome variables: family confer-
ences (ie, formal family meetings), code discussions,
and ethics consultations. Secondary clinical outcomes
included social work, chaplain, and palliative care
consultations, which referred to actual visits from rep-
resentatives of these disciplines. In all settings, pallia-
tive care required physician orders, whereas ethics,
social work, and chaplain referrals could be made by
all members of the health care team.
Data Sources Using the same data abstraction instrument at
all sites, either the site’s primary investigator, nurse,
or trained research assistant abstracted outcome data
We measured number and timing of family conferences and code discussions as well as referrals to support ser- vices at baseline and 3 and 6 months after the intervention.
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52 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2020, Volume 29, No. 1 www.ajcconline.org
from the electronic health record for 1 month before
the intervention and for 1 month at 3 and 6 months
after the intervention. Two units abstracted data only
before the intervention and at 6 months after the
intervention. Information on family conferences
and code discussions was extracted from narrative
notes made by physicians, nurses, and social work-
ers. The ethics consultation service in each setting
provided data on ethics consultations for the ICU
site. Poststudy focus groups were held at study sites
to identify benefits, challenges, and suggestions for
improvement.
Statistical Analysis All data analyses were conducted using SAS,
version 9.4. As noted previously, patient ICU admis-
sions (1712) rather than patients (1649) were used
as sample units. Additionally, data were analyzed
according to type of ICU, so we combined medical
ICU data from 2 hospitals. Differences in patients’
demographics between the preintervention and
postintervention groups were explored using 2
analyses for dichotomous variables and t tests or
analyses of variance for normally distributed con-
tinuous variables. To ascertain whether significantly
more patient admissions were receiving family con-
ferences, social work consultations, palliative care
consultations, code status
discussions, chaplain visits,
and ethics consultations at
follow-up compared with
before the intervention, sim-
ple bivariate (unconditional)
logistic regression analyses
were performed comparing
preintervention and postin-
tervention time points. Mul-
tivariate logistic regressions
of the same outcomes com-
paring preintervention and
postintervention time points
were also performed, con-
trolling for all patient demographic variables, pri-
mary diagnosis, ICU type, and ICU length of stay.
Because postintervention data at 3 months repre-
sented 3 ICU types, all analyses comparing prein-
tervention with 3 months postintervention were
performed for these 3 ICU types. Separate analyses
were performed comparing preintervention with
6-month postintervention data for all 5 ICU types.
To determine whether the incidence ratio of receiv-
ing a family conference differed on any given day
between the preintervention and 3-month postin-
tervention and the preintervention and 6-month
postintervention time points, survival analyses were
conducted by using multivariate Cox regression mod-
els, controlling for all patient demographic variables,
ICUs, primary diagnoses, and ICU length of stay.
Results The sample consisted of 1712 admissions for 1649
patients who entered the ICU during the data collec-
tion time periods: 672 admissions in the preinterven-
tion period, 438 in the 3-month postintervention
period, and 602 in the 6-month postintervention
period. Most patients were admitted for an acute
illness. Although some surgical admissions in 1 unit
were elective, most of those patients were experienc-
ing life-threatening conditions requiring surgical
intervention. Most of the patients were white (74%)
and male (56%), and the mean age of the patients
was 60 years. Patients in the preintervention and
postintervention groups did not differ significantly
in terms of demographic variables except for reli-
gion, primary diagnosis, and ICU type (Table 1).
Additionally, the percentages of patients who had
an advance directive (47%, 44%, and 47%), provider
or medical orders for life-sustaining treatments (all
7%), or a named surrogate (56%, 52%, and 60%)
did not differ significantly among the 3 groups.
Clinical Outcomes In our comparison of preintervention and 3- and
6-month postintervention data, we noted increases
in the proportion of admissions with family confer-
ences (12%, 21%, 20%), chaplain visits (23%, 25%,
33%), code discussions (17%, 18%, 21%), social
work visits (39%, 35%, 47%), and palliative care
consultations (5%, 6%, 7%). Controlling for demo-
graphic variables, diagnosis, ICU type, and ICU
length of stay, ICU admissions at both 3 months
(Table 2) and 6 months after the intervention (Table
3) had significantly higher odds of receiving a family
conference, with odds ratios (ORs) of 2.54 (P < .001)
for 3 months and 1.77 (P = .001) for 6 months com-
pared with preintervention admissions. The odds of
experiencing a chaplain visit significantly increased
at both 3 months (OR = 1.59, P = .008) and 6 months
(OR = 1.65, P = .001) after the intervention compared
with before the intervention.
The odds of receiving a palliative care consulta-
tion or code status discussion did not differ signifi-
cantly at 3 months (OR = 1.12 for palliative care
consultation and 1.40 for code status discussion) or
6 months (OR = 1.38 for palliative care consultation
and 1.33 for code discussion) compared with before
the intervention. Admissions at 6 months had signifi-
cantly higher odds of receiving social work referrals
Patients admitted to the intensive care unit
3 and 6 months after the intervention had significantly higher odds of receiving a
family conference than at baseline.
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Timing relative to intervention
Characteristic Before (n = 660) 3 Months after (n = 408) 6 Months after (n = 581)
Table 1 Demographic characteristics of 1649 patients at 3 time pointsa
a Values in last 3 columns are No. (%) of patients. b P < .001. c P = .001. d The 2 test was not reliable because of empty cells.
Age, y 40 82 (12.4) 71 (17.4) 89 (15.3)
41-60 200 (30.3) 132 (32.4) 180 (31.0) 61-75 244 (37.0) 118 (28.9) 185 (31.8) 76 134 (20.3) 87 (21.3) 127 (21.9)
Sex Female 275 (41.7) 194 (47.5) 249 (42.9) Male 385 (58.3) 214 (52.5) 332 (57.1)
Race/ethnicity White 501 (75.9) 294 (72.1) 436 (75.0) Asian 25 (3.8) 21 (5.1) 26 (4.5) Black 33 (5.0) 29 (7.1) 32 (5.5) Hispanic 48 (7.3) 45 (11.0) 62 (10.7) Other/no report 53 (8.0) 19 (4.7) 25 (4.3)
Religionb
Christian (Protestant) 275 (41.7) 173 (42.4) 178 (30.6) Catholic 176 (26.7) 92 (22.5) 186 (32.0) Other 41 (6.2) 29 (7.1) 34 (5.9) No report 168 (25.5) 114 (27.9) 183 (31.5)
Diagnosis categoryc
Organ failure 202 (30.6) 134 (32.8) 211 (36.3) Postoperative monitoring and complications 152 (23.0) 103 (25.2) 110 (18.9) Neurologic/spinal condition 72 (10.9) 66 (16.2) 74 (12.7) Sepsis/infection 71 (10.8) 35 (8.6) 75 (12.9) Other conditions 163 (24.7) 70 (17.2) 111 (19.1)
Type of intensive care unitb,d Cardiac surgery 72 (10.9) 0 (0.0) 79 (13.6) Transplant 70 (10.6) 90 (22.1) 70 (12.0) Medical 327 (49.5) 187 (45.8) 323 (55.6) Neurologic 145 (22.0) 131 (32.1) 80 (13.8) Surgical/trauma 46 (7.0) 0 (0.0) 29 (5.0)
Outcomes at 3 monthsc Coefficient SE P Odds ratio 95% CI of odds ratio
Table 2 Time of admission (baseline, 3 months) as predictor of receiving family conference, code status discussion, palliative care consultation, social work consultation, and chaplain visita,b
a Data from multivariate logistic regression models, with demographic characteristics, intensive care unit length of stay, diagnosis, and intensive care unit specialty controlled for.
b Includes data from medical, neurological, and transplant (not surgical/trauma or cardiac surgery) intensive care units. c Compared with before intervention. d Area under receiver operating characteristic curve = 0.74, Hosmer-Lemeshow P value = .66. e Area under receiver operating characteristic curve = 0.68, Hosmer-Lemeshow P value = .28. f Area under receiver operating characteristic curve = 0.77, Hosmer-Lemeshow P value = .53. g Additionally controlled for code status at admission. h Area under receiver operating characteristic curve = 0.74, Hosmer-Lemeshow P value = .76. i Area under receiver operating characteristic curve = 0.69, Hosmer-Lemeshow P value = .49.
Family conferenced 0.47 0.10 <.001 2.54 1.72-3.77
Social work consultatione −0.03 0.07 .69 0.94 0.71-1.25
Palliative care consultationf 0.06 0.15 .71 1.12 0.62-2.05
Code status discussiong,h 0.17 0.10 .08 1.40 0.96-2.04
Chaplain visiti 0.23 0.09 .008 1.59 1.13-2.23
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(OR = 1.34, P = .02) compared with before the inter-
vention. The number of ethics consultations was
low before the intervention (N = 6) and increased to
14 at 3 months and 14 at 6 months after the inter-
vention. The number of ICU admissions with “code
status not discussed” was 136 (20%) before the inter-
vention and decreased to 27 (6%) at 3 months and
64 (11%) at 6 months after the intervention.
To ascertain whether time to first family confer-
ence differed significantly between the preinterven-
tion period and each of the postintervention periods,
we performed survival analysis using Cox regression
models, controlling for all patient demographic vari-
ables including primary diagnosis and ICU type. At
any particular time, with all covariates controlled
for, a little more than twice
as many admissions from
the 3-month postinterven-
tion period received a family
conference compared with
preintervention admissions
(hazard ratio [HR] = 2.22,
P < .001; Table 4). At 6 months,
this ratio decreased slightly
to 1.73 (P < .001), indicat-
ing 73% more admissions
receiving a family confer-
ence on a certain day com-
pared with preintervention
admissions, with all other
covariates controlled for (Table 5). Kaplan-Meier
survival graphs 1 and 2 (Figures 2 and 3, available
online only) illustrate these findings. No signifi-
cant differences were found for other timing vari-
ables or ICU length of stay.
The incidence of having a family conference
differed significantly across ICU types. At 3 months,
both transplant ICU and medical ICU admissions
had HRs more than twice that of neurologic ICU
admissions. At 6 months, HRs ranged from 2.99 for
the surgical/trauma ICU to 5.09 for the cardiac sur-
gery ICU compared with the neurologic ICU, indi-
cating that neurologic ICU admissions had the lowest
likelihood of receiving family conferences among all
the ICU types. Patients’ age also differed significantly
in the comparison between baseline and 6 months,
with all other variables in the model controlled for.
Patients older than 75 years were significantly more
likely to receive a family conference than those in
younger age groups, with HRs ranging from 0.32 for
the 40 years or less age group to 0.54 for the 61 to
75 years age group (Table 5).
Discussion This study offers some evidence that routine
implementation of a team-based ethics intervention
can provide additional resources to patients and
families during critical illness. The Ethics Early Action
Protocol resulted in more formal communication
with family members and increased attention to
spiritual care needs. We also found that code status
was discussed more often, which could indicate that
the ethics protocol increased awareness and improved
documentation regarding code status. Because moral
distress is associated with delays in end-of-life con-
versations, opportunities to have these team discus-
sions seem essential.29
Although the number of patients who received
chaplain visits at all 3 time points was low in our study
(23% before the intervention, 25% at 3 months after
the intervention, and 33% at 6 months after the
intervention), the protocol significantly increased
these visits. Evidence from other studies indicates
that although physicians and nurses value spiritual
care,30,31 providers rarely explore patients’ spiritual
needs,32 despite evidence of the benefits of spiritual
care such as improved quality of life33 and increased
satisfaction of patients.34,35 Routinely assessing patients’
Outcomes at 6 monthsb Coefficient SE P Odds ratio 95% CI of odds ratio
Table 3 Time of admission (baseline, 6 months) as predictor of receiving family conference, code status discussion, palliative care consultation, social work consultation, and chaplain visita
a From multivariate logistic regression models, controlling for demographic characteristics, diagnosis, and intensive care unit specialty. b Compared with before intervention. c Area under receiver operating characteristic curve = 0.70, Hosmer-Lemeshow P value = .49. d Area under receiver operating characteristic curve = 0.70, Hosmer-Lemeshow P value = .50. e Area under receiver operating characteristic curve = 0.70, Hosmer-Lemeshow P value = .73. f Area under receiver operating characteristic curve = 0.71, Hosmer-Lemeshow P value = .41. g Additionally controlled for code status at admission. h Area under receiver operating characteristic curve = 0.67, Hosmer-Lemeshow P value = .84.
Family conferencec 0.29 0.09 .001 1.77 1.27-2.48
Social work consultationd 0.15 0.06 .02 1.34 1.05-1.70
Palliative care consultatione 0.16 0.13 .20 1.38 0.84-2.25
Code status discussionf,g 0.14 0.08 .08 1.33 0.97-1.81
Chaplain visith 0.25 0.07 .001 1.65 1.23-2.21
The odds of receiving a visit from a chaplain increased significantly at 3 and 6 months after
the ethics protocol was implemented
compared with before the intervention.
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and families’ spiritual needs and providing support
may be an overlooked aspect of critical care.
In our study, the number of ICU admissions that
included at least 1 family conference increased signifi-
cantly with protocol use. Evidence from other studies
indicates that families not only benefit from family
conferences36 but also value the opportunity,37 espe-
cially if provided time to share their perspectives.38
Communication with patients and their families is
a cornerstone of shared decision-making39 and pro-
vides an opportunity for clinicians to prepare surro-
gates for informed decision-making. Improving
family-clinician communication increases family
members’ confidence in treatment decision-making
and shortens the duration of life support among
patients who die in the ICU,40 promotes earlier con-
sensus on goals of care for trauma patients41 and liver
transplant patients,42 and improves family satisfaction
with end-of-life care in the ICU.43
Another important resource for patients and
families during critical illness is team collaboration.
Teamwork is associated with factors that decrease
inappropriate treatments,44 increase information
exchange among teams,45 and decrease moral dis-
tress.4 In our study, the protocol prompted routine,
team-based conversations about ethics-related aspects
of care such as patients’ preferences, family perspec-
tives, treatment benefits and burdens, and goals of
care. Nurses who participated in poststudy focus
groups at study sites indicated that proactive, team-
based communication guided by the ethics protocol
helped to clarify care goals, identify different view-
points, coordinate care, and initiate early actions that
provided multidisciplinary care for patients and offered
informational and emotional support for families.
Our study also revealed potential gaps in ICU
care. For example, very few ICU patients received
palliative care consultation. Evidence suggests that
patients with advanced heart failure who receive
usual care plus a palliative care intervention mani-
fest less anxiety and depression and enhanced spiri-
tual well-being compared with similar patients who
Characteristic Coefficient SE P Hazard ratio 95% CI of hazard ratio
Table 4 Proportional hazard of receiving a family conference at 3 months after the intervention compared with before the intervention, using Cox regression model
a Compared with before intervention. b Compared with age > 75 years. c Compared with male sex. d Compared with non-Hispanic white. e Compared with neurologic intensive care unit. f Compared with no religion. g Compared with sepsis or infection.
Time of admissiona
3 months after intervention 0.80 0.18 < .001 2.22 1.56-3.15
Age,b y 40 −0.52 0.31 .09 0.60 0.33-1.09
41-60 −0.56 0.25 .03 0.57 0.34-0.94 61-75 −0.39 0.24 .11 0.68 0.43-1.09
Female sexc 0.12 0.17 .46 1.13 0.81-1.58
Race/ethnicityd
Asian 0.26 0.33 .44 1.29 0.67-2.48 Black 0.32 0.30 .28 1.38 0.77-2.47 Hispanic 0.27 0.26 .29 1.31 0.79-2.17 Other/no report −0.14 0.29 .64 1.15 0.65-2.04
Type of intensive care unite
Transplant 0.72 0.40 .08 2.05 0.93-4.52 Medical 0.95 0.39 .02 2.58 1.19-5.57
Religionf
Catholic −0.39 0.25 .12 0.68 0.42-1.10 Christian (Protestant) −0.04 0.22 .84 0.96 0.63-1.47 Other 0.22 0.30 .45 1.25 0.70-2.23
Primary diagnosisg
Neurologic/spinal −0.31 0.39 .43 0.74 0.34-1.58 Organ failure −0.30 0.26 .25 0.74 0.45-1.23 Postoperative monitoring and
complications −0.72 0.36 .04 0.49 0.24-0.98
Other −0.10 0.29 .73 0.91 0.52-1.59
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56 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2020, Volume 29, No. 1 www.ajcconline.org
receive only the usual, standard treatment for heart
failure.46 Positive outcomes have also been noted for
patients diagnosed with metastatic non–small cell
lung cancer who receive standard oncology care plus
palliative care, compared
with those who receive
standard care alone. The
palliative care plus stan-
dard therapy group had
significant improvements
in perception of quality
of life and mood, received
less aggressive care at
the end of life, and lived longer.47 On the basis of
its effectiveness, proactive palliative care is now rec-
ommended.48 In our study, palliative care was an
underused resource for ICU patients.
Very few ethics consultations occurred during
the study period. Similarly, a prospective study
conducted in an oncology ICU revealed that only
1% of ICU admissions had an ethics consultation;
when implemented, ethics consultation reduced
surrogate-clinician disagreements and increased
referrals to palliative care and chaplain services.49
Proactively offering valuable ethics-related resources
to patients, families, and health care providers may
improve patient outcomes such as quality of life,
promote family trust and satisfaction with care, and
prevent provider disengagement.9
Limitations A nonrandom and relatively small (3 months of
patient admissions) sample naturally limits the study
findings. The quasi-experimental, pre-post design
does not account for variables that may have changed
during the study time period, such as staffing changes.
However, collecting data in 3 different settings and
geographic regions helps to offset design limitations.
The protocol prompted routine team-based con- versations about ethics- related aspects of care.
Characteristic Coefficient SE P Hazard ratio 95% CI of hazard ratio
Table 5 Proportional hazard of receiving a family conference at 6 months after the intervention compared with before the intervention, using Cox regression model
a Compared with before intervention. b Compared with > 75 years. c Compared with male sex. d Compared with non-Hispanic white. e Compared with neurologic intensive care unit. f Compared with no religion. g Compared with sepsis or infection.
Time of admissiona
6 months after intervention 0.55 0.15 < .001 1.73 1.29-2.33
Age,b y 40 −1.15 0.29 < .001 0.32 0.18-0.56
41-60 −0.66 0.20 .001 0.52 0.35-0.77 61-75 −0.62 0.19 .001 0.54 0.37-0.78
Female sexc −0.18 0.15 .23 0.84 0.63-1.12
Race/ethnicityd
Asian 0.20 0.31 .43 1.23 0.67-2.26 Black 0.03 0.33 .92 1.04 0.54-1.98 Hispanic 0.35 0.24 .15 1.42 0.88-2.29 Other/no report −0.50 0.31 .11 0.61 0.33-1.11
Type of intensive care unite
Cardiac surgery 1.62 0.48 < .001 5.09 1.98-13.06 Transplant 1.26 0.49 .01 3.54 1.36-9.19 Medical 1.40 0.46 .002 4.07 1.65-10.02 Surgical/trauma 1.09 0.54 .04 2.99 1.03-8.69
Religionf
Catholic −0.23 0.21 .26 0.79 0.53-1.19 Christian (Protestant) −0.02 0.19 .91 0.98 0.67-1.43 Other 0.11 0.28 .71 1.11 0.64-1.92
Primary diagnosisg
Neurologic/spinal 0.46 0.34 .18 1.58 0.81-3.08 Organ failure 0.10 0.23 .68 1.10 0.70-1.74 Postoperative monitoring and
complications −0.35 0.30 .24 0.70 0.39-1.27
Other 0.09 0.26 .73 1.10 0.66-1.83
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www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2020, Volume 29, No. 1 57
Even though site investigators worked from common
outcome definitions, outcome data were sometimes
difficult to extract because electronic health records
did not have standardized chart locations for docu-
menting family conferences or code discussions.
Instead, investigators had to rely on reading health
care providers’ narrative notes. This limitation was
in effect at all 3 time points and in all settings. Fam-
ily conference documentation may account for some
of the results, although nurses participating in the
focus groups commented frequently on how the
protocol increased family conferences. One nurse
commented, “Before the protocol, scheduling a fam-
ily conference was like pulling teeth, putting them
back in, and pulling them out again. Now they [family
conferences] just happen.” To deepen understandings
about the protocol’s impact, direct patient and fam-
ily outcome measures should be included in future
studies, along with direct observations of clinical
outcomes such as family conferences. Differences in
ICU types also need further exploration.
Conclusion This study provides some evidence that the team-
based Ethics Early Action Protocol increases family
conferences, which could provide opportunities for
sharing important information about patients. The
ethics protocol also offers spiritual resources that
could provide valuable support for patients and their
families during critical illness. Data from other stud-
ies suggest that family conferences, spiritual support,
palliative care interventions, and ethics consultations
can improve patient experiences and contribute to
family-team cohesiveness.21,24,35,36,43,46,47 In total,
these findings suggest that routine efforts such as
the Ethics Early Action Protocol to provide more
patient care services and promote interprofessional
teamwork may be a valuable asset for critically ill
patients and their families.
FINANCIAL DISCLOSURES This study was supported by an American Association of Critical-Care Nurses Impact Grant.
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1.0 Hour Category CC E Notice to CE enrollees:
This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the
following objectives:
1. Identify the purpose of initiating routine, team-based dialogue on ethical aspects of care for critically ill
patients and their families.
2. Describe risk factors that increase the possibility of ethical conflicts developing in situations involving
patients in an intensive care unit.
3. Analyze the benefits of early identification and team-based planning for ethically complex situations.
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40. Majesko A, Hong SY, Weissfeld L, White DB. Identifying family members who may struggle in the role of surrogate decision maker. Crit Care Med. 2012;40(8):2281-2286.
41. Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Livingston DH. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;64(6): 1587-1593.
42. Lamba S, Murphy P, McVicker S, Harris Smith J, Mosenthal AC. Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012;44(4):508-519.
43. Hinkle LJ, Bosslet GT, Torke AM. Factors associated with family satisfaction with end-of-life care in the ICU. Chest. 2015;147(1):82-93.
44. Kross EK, Curtis JR. ICU clinicians’ perceptions of appropri- ateness of care and the importance of nurse-physician col- laboration. Arch Intern Med. 2012;172(11):889-890.
45. Mayo AT, Woolley AW. Teamwork in health care: maximizing collective intelligence via inclusive collaboration and open communication. AMA J Ethics. 2016;18(9):933-940.
46. Rogers JG, Patel CB, Mentz RJ, et al. Palliative care in heart failure: the PAL-HF randomized, controlled clinical trial. J Am Coll Cardiol. 2017;70(3):331-341.
47. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
48. Gerritson RT, Hartog CS, Curtis JR. New developments in the provision of family-centered care in the intensive care unit. Intensive Care Med. 2017;43(4):550-553.
49. Voigt LP, Rajendram P, Shuman AG, et al. Characteristics and outcomes of ethics consultations in an oncologic intensive care unit. J Intensive Care Med. 2015;30(7):436-442.
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Ethics Early Action Protocol© This form is intended to be used as a tool to assess potential risk factors for ethical conflict related to health care decision-making and to identify resources for addressing such potential conflict. The form is intended to facilitate conversation and communication among team members, patients, and families and provide possible tools for problem-solving and enhancing health care. The form is not intended to serve as a progress note or the final documentation of a patient’s status or medical diagnosis.
PATIENT SITUATION
Date: Patient Initials: Hospital Day: Unit:
Primary Diagnosis:
Other Diagnoses:
Patient Situations as Discussed in Multidisciplinary Rounds
Sepsis/infectious process
Acute medical deterioration
Organ failure (cardiac, respiratory, renal, liver)
Stroke/neurologic complications
Hemorrhage (GI bleed, DIC)
Postsurgical observation
Trauma
Transplant
Drug overdose/poisoning
End of life
Other (please specify)
ETHICS ASSESSMENT
Temporary Advance Directive Yes No Advance Health Care Directive Yes No POLST Yes No
Decision-maker/Surrogate Known Unknown Name and contact information:
Code Status Full Code DNR Partial/DNI
Initial date ordered: If changed, date of change:
Patient’s Age: Gender: Female Male Code#
Race/Ethnicity Religion American Indian/Alaskan Native Buddhist
Asian Christian
Black/African American Hindu
Hispanic/Latino Jewish
Native Hawaiian/Pacific Islander Catholic
White Muslim
Middle Eastern No religious affiliation
Other
Risk Factors for an Ethical Conflict
Patient Risk Factors:
**Is there potential for escalation of nonbeneficial treatment?
**Is there a combination of patient lacking decisional capacity and family conflict?
**Does the patient have compromised capacity and no decision-maker?
**Is the patient suffering? (ie, physical, psychological, or spiritual pain or high anxiety)
Does the patient appear to be imminently dying?
Is the patient vulnerable due to factors such as compromised capacity, mental illness, substance abuse, lack of education/ literacy, very old or very young, low socioeconomic status, homeless, and/or inadequate support system?
Is the patient vulnerable due to communication concerns, such as non-English speaker, limited English proficiency, limited literacy, blind, deaf, or very hard of hearing?
Does the patient have complex health care needs with uncertain prognosis?
Have there been a series of unsuccessful treatments and/or a worsening prognosis?
Is the patient refusing clinically beneficial treatments?
Figure 1 Ethics Early Action Protocol completed daily by clinicians. Abbreviations: DIC, disseminated intravascular coagulation; DNI, do not intubate; DNR, do not resuscitate; GI, gastrointestinal; ICU, intensive care unit;
POLST, physician/provider orders for life-sustaining treatment. ©2015 by Pavlish, Brown-Saltzman, Henriksen Hellyer, Jakel, and Robinson. Continued
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Family Risk Factors
**Is there conflict between family members about the plan of care?
** Does a family member have strong beliefs or views about how care should be provided?
** Are there cultural or faith beliefs that influence expectations?
Are there communication barriers between the family and health care team such as non-English speakers, limited English proficiency, limited literacy, blind, deaf, or hard of hearing?
Is there disagreement between the health care team and the family about the plan of care or view of prognosis?
Is the family discussing legal action?
Is the family uncertain about the plan of care?
Has family been absent or unavailable?
Situational Risk Factors
**Is there a need for conversation about the goals of care and/or for a cohesive plan of treatment?
**Is there concern about patient autonomy and/or patient’s known wishes for care?
**Is there concern about the patient’s right to information?
**Are there signs of moral distress in families and/or clinicians?
Is there a need for coordinated communication with patient, with family, or within the health care team?
Is there compromised trust?
Is there a need for clarification about standard of care for patient/family?
Is there a need for better understanding of the condition or prognosis?
Is there need for clarification of patient preferences (eg, advance directive)?
Has conflict been observed?
High Risk of Conflict Ethics conflict is likely or very likely to
develop (more than 6 risk factors checked or ANY critical risk factor checked)
Actions: Review advance directive/POLST; if
none, provide resources.
Identify whether a surrogate has been named in the event the patient loses capacity.
Provide daily updates on patient’s condition: offer honest/direct information, use common lan- guage, and avoid euphemisms and complex medical terms.
Discuss the situation with your lead- ership.
Request a meeting with the multi- disciplinary health care team.
Consult with social worker, palliative care, and spiritual care if appropri- ate.
Initiate plans for ongoing surrogate/ family conferences.
Call for formal ethics consultation.
Continue to monitor situation.
Medium Risk of Conflict Ethics conflict has moderate potential
for developing (4-6 risk factors checked)
Actions: Review advance directive/POLST; if
none, provide resources.
Identify whether a surrogate has been named in the event the patient loses capacity.
Provide daily updates on patient’s condition: offer honest/direct information, use common lan- guage, and avoid euphemisms and complex medical terms.
Initiate conversation with your lead- ership (nurse and physician lead- ers).
Discuss situation with the multidisci- plinary health care team.
Arrange for surrogate/family confer- ence.
Consider consultation with ethics service, social worker, palliative care, spiritual care.
Continue to monitor situation.
Low Risk of Conflict Ethics conflict unlikely at this time
(3 or fewer risk factors checked)
Actions: Review advance directive/POLST; if
none, provide resources.
Identify whether a surrogate has been named in the event the patient loses capacity.
Provide daily updates on patient’s condition: offer honest/direct information, use common lan- guage, and avoid euphemisms and complex medical terms.
Discuss with colleague if needed.
Consult with social worker.
Consult with spiritual care if appro- priate.
Continue to monitor situation.
**Indicates critical risk factor
Ethics Plan With Suggested Follow-up Actions
(Note whether action is completed, in progress, or not done at this time) (Ethics assessment and plan conducted within 48 hours of admission to ICU and considered daily thereafter)
Figure 1 Continued
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Figure 2 Kaplan-Meier survival graph shows that patients admitted to the intensive care unit 3 months after the intervention was implemented had a higher probability of experiencing a family conference and would have the con- ference sooner than would patients admitted before the intervention was implemented.
Figure 3 Kaplan-Meier survival graph shows that patients admitted to the intensive care unit 6 months after the intervention was implemented had a higher probability of experiencing a family conference and would have the con- ference sooner than would patients admitted before the intervention was implemented.
1.0
0.8
0.6
0.4
0.2
0.0
1.0
0.8
0.6
0.4
0.2
0.0
C u
m u
la ti
ve s
u rv
iv al
C u
m u
la ti
ve s
u rv
iv al
Days elapsed before family conference
Days elapsed before family conference
Before
Before
3 months after
6 months after
0 10 20 30 40
0 10 20 30 40
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